Results 1 to 6 of 6

V58.11 primary or secondary or tertiary. Does order matter?

  1. Angry V58.11 primary or secondary or tertiary. Does order matter?
    Medical Coding Books
    Does it matter the order or placement of V58.11, versus the cancer diagnoses? We have some payers that reject our chemo claims when V58.11 is primary. It is a system issue, and they aren't able to match the drug with an approved cancer dx, so the system denies, stating no auth or not covered. I am trying to work with our coding department to get some documentation to show that we can move this dx to the 2nd, 3rd, or 4th placement. They insist that the "reason for visit" is to receive chemo, so this has to be primary. This is causing a TON of needless appeals. Any suggestions? Any documentation? HELP!

  2. #2
    Location
    Columbia, MO
    Posts
    12,909
    Default
    V58.11 is a first-listed only dx code. This is stated in the coding guidelines. If you are being denied because your drug and the cancer dx do not match then it is a medical necessity issue and place the V58.11 secondary will not fix it. However if you drug is not chemo then do not use V58.11. Not all antineoplastic drugs are chemo.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    New Windsor, New York
    Posts
    1,183
    Default Check the payers
    While Deborah is correct about the coding guidelines and V58.11 should always be listed first, payers sometimes DO make thier own rules that go against the guidelines - even government payers.

    For example, we all know to code for diabtes first then the manifestation. However, in the NGS LCD for HBO, if it is used to treat a diabetic ulcer, they deny claims that list the 250 code first - they are looking for the 707 code first, then the diabetes.

    So for the question, be sure to check these payers for any rules they have that may go against coding guidelines.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

  4. #4
    Location
    Columbia, MO
    Posts
    12,909
    Default
    Quote Originally Posted by MnTwins29 View Post
    While Deborah is correct about the coding guidelines and V58.11 should always be listed first, payers sometimes DO make thier own rules that go against the guidelines - even government payers.

    For example, we all know to code for diabtes first then the manifestation. However, in the NGS LCD for HBO, if it is used to treat a diabetic ulcer, they deny claims that list the 250 code first - they are looking for the 707 code first, then the diabetes.

    So for the question, be sure to check these payers for any rules they have that may go against coding guidelines.
    The coding guidelines for ICD-9 and 10 are mandated by HIPAA for adherence. Therefore payers cannot have their own rules regarding diagnosis code assignment unless they are a non HIPAA such as work comp. look on page one of the guidelines

    Debra A. Mitchell, MSPH, CPC-H

  5. Cool Payer Difference
    We code different for commercial payers vs. Medicare. Medicare we code the cancer code first, commercial we code the V-code first. Payers are not supposed to have their own rules, but it seems they find ways to "sneak" around the guidelines sometimes!

  6. #6
    Location
    Columbia, MO
    Posts
    12,909
    Default
    The diagnosis coding guidelines are not Medicare guidelines, they were created by the CDC for compliance when applying the code set and they mandated to be adhered to under HIPAA, the only payers they do not apply to are non HIPAA like work comp. if you use the V58.11 as a secondary code it is non compliant, if you code the diabetes code secondary for diabetic complications then it is non compliant. These rules were put into place for consistency. A payer cannot dictate which dx codes you can use or what order they can be in. They can make directives regarding medical necessity and coverage. If you "adjust" your dx code assignment to meet a payer "rule" you may be assigning a code that is incorrect for the patient.

    Debra A. Mitchell, MSPH, CPC-H

Similar Threads

  1. primary vs. secondary DM II
    By BrenLea14 in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 11-02-2014, 04:30 AM
  2. Auto/ Primary/ Secondary billing order
    By gtaylor in forum Billing/Reimbursement
    Replies: 1
    Last Post: 04-03-2012, 03:13 PM
  3. Reporting V58.69 as primary diagnosis
    By kpennington in forum E/M
    Replies: 4
    Last Post: 02-19-2010, 06:25 AM
  4. using V58.1x as primary
    By coder in mo in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 06-17-2008, 02:39 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.